A COVID-19 Focused Emergency Preparedness Survey was conducted by the Oregon State Survey Agency from 1/20/21 to 1/27/21. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total residents: 57
A COVID-19 Focused Infection Control Survey and complaint (Intake #s 24200, 27766 and 27988) health survey was conducted by the Oregon State Survey Agency on 1/20/21 to 1/27/21. The facility was found to be in compliance with 42 CFR ยง483.80.
Total residents: 57
A COVID-19 Infection Control Survey and complaint (Intake #s: 24200, 27766 and 27988) health survey and COVID-19 Confirmed Facility Review were conducted by the Oregon State Survey Agency on 1/20/21 to 1/27/21.
Total residents: 57
Deficiencies were cited.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the revisit to the complaint (intake #s 24200, 27766 and 27988) health survey conducted 3/25/21 through 3/29/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
Based on interview and record review it was determined the facility failed to legibly, thoroughly and accurately complete the Direct Care Staff Daily Report for 19 out of 81 days reviewed for staffing. This placed residents and the public at risk for lack of accurate staffing information.
The Direct Care Staff Daily Reports revealed the facility failed to write legibly and/or write the hours staff worked on the following dates:
11/2020: 11/10, 11/12, 11/14, 11/15, 11/16, 11/29;
12/2020: 12/11;
1/1/21 through 1/20/21: 1/1, 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/12, 1/13, 1/16.
In an interview on 1/27/21 at 1:15 PM Staff 1 (Administrator) stated she expected Direct Care Staff Daily Reports be completed accurately and legibly.
M180 Nursing Services: Daily Staff Public Posting Corrective Action(s) for residents identified to have been affected. No residents identified to be potentially affected. Identified of residents with the potential to be affected. No residents identified to be affected. Measured to prevent recurrence: Staffing coordinator will ensure daily staff public posting is legible, thorough, and accurate. All RNs and LPNs re-educated on the need to complete the DHS Staffing Sheet at the start of every shift and to ensure it is accurate, legible and includes actual hours worked by clinical staff. Monitor for Corrective Action: The Administrator or designee will audit weekly for 4 weeks to monitor for accurate public posting. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Plan will be developed as necessary.
Based on interview and record review it was determined the facility failed to meet mandated CNA staffing ratios for 13 out of 60 shifts reviewed for 1/2021 staffing. This placed residents at risk for unmet needs: Findings include:
A review of the 1/1/21 through 1/20/21 Direct Care Staff Daily Reports revealed the facility had insufficient CNA staff 13 of 60 shifts:
-1/2 day;
-1/3 day and evening;
-1/4 evening;
-1/5 evening and overnight;
-1/6 day;
-1/8 evening;
-1/9 overnight;
-1/10 day and evening;
-1/11 day and overnight.
In an interview on 1/27/21 at 1:15 PM Staff 1 (Administrator) stated she was aware the facility had staff shortages. Staff 1 stated she expected minimum staff ratio requirements were met.
M183 Minimum CNA Staffing Corrective Action(s) for residents identified to have been affected. No residents identified to be potentially affected. Identified of residents with the potential to be affected Residents have the potential to be affected by insufficient staffing. Measured to prevent recurrence: Staffing coordinator will call all available staff who is currently not working. Call sister facilities for staffing. Call prestige pool and agency. Work with recruitment to hire more staff and hire Personal Care Assistant. Have RCMs, DNS and licensed nurses work the floor to provide direct care. Monitor for Corrective Action: The Administrator or designee will audit weekly for 4 weeks ensure the facility is meeting mandated staffing ratios. Any Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Plan will be developed as necessary.
